By David I. Feldman, MD, MPH; Kim Cuomo, CRNP; Roger S. Blumenthal, MD; Roberta Florido, MD, MHS
The American College of Cardiology and the American Heart Association updated the guideline for managing heart failure in 2017. Here are key points that all patients with heart failure should know about healthy lifestyle and proven medications, new heart failure medications, patient self-monitoring, physical activity, and the impact of diabetes.
In patients with a history of heart failure, implementing evidence-based dietary and medication changes helps promote recovery and prevent disease progression.
The first step in controlling cardiovascular disease risk factors (including high blood pressure, cholesterol, obesity, and diabetes mellitus) is following a heart-healthy diet, increasing daily physical activity levels, reducing sedentary behavior, and avoiding tobacco products. These changes include replacing most saturated fats, red meat, and processed foods in the diet with fruits and vegetables, lean protein, whole grains, and healthy oils. Restricting sodium intake to fewer than 2,000 mg per day and limiting fluid intake to fewer than 64 ounces a day may also help reduce the risk for heart failure symptoms.
The cornerstone of managing heart failure is guideline-directed medical therapy, which is proven to reduce symptoms, repeat hospitalizations, and deaths. Nearly all patients with coronary artery disease and signs or symptoms of heart failure should be started on the following:
Medication doses will be optimized over time. This usually involves increasing the dosage of the medication to the maximal level tolerated by patients. By helping to lower blood pressure, cholesterol and stress on the heart, these medications will promote healing and improve heart function. Often, making these dietary and medication changes will improve heart failure signs and symptoms.
If the patient continues to have symptoms of heart failure (such as shortness of breath with moderate walking or climbing stairs) despite following the medical therapy as outlined above, other treatment options exist and should be discussed with the cardiovascular specialist.
Consideration can be given to adding a mineralocorticoid receptor antagonist (MRA) such as spironolactone to address fluid retention, changing the ACE-I or ARB to an angiotensin receptor blocker/neprilysin inhibitor (ARNI) or both. An MRA or ARNI are often considered for all patients with at least moderate impaired heart muscle function (Ejection Fraction <40%) even if they do not have complaints of shortness of breath with exercise.
For several decades, ACE-I medications, like enalapril, have been the foundation for treatment of heart failure, as they are proven to reduce morbidity and mortality. Years later, ARBs, like valsartan demonstrated similar effects on heart failure outcomes. In 2014, researchers studied whether a combination pill of valsartan/sacubitril (ARNI) when compared with an ARB alone would reduce mortality and heart failure hospitalizations in an at-risk population (persons with a weakened heart muscle and at least mild shortness of breath with ordinary activity).
Results of the trial revealed the combination pill to be superior, which led the FDA to fast-track the ARNI for approval. It is now recommended that ALL patients with clinically significant symptomatic heart failure who tolerate ACE-I or ARB medications strongly consider switching to the combination of valsartan/sacubitril (ARNI) for additional reduction in morbidity and mortality.
While monitoring symptoms and disease progression is critical for all patients with heart failure, it is a multifaceted process that requires education to help facilitate self-care. One aspect of this process is tracking weight fluctuations, which is a simple way to determine volume status. Heart failure symptoms occur when patients are volume overloaded or are above their "dry weight."
A patient’s "dry weight" correlates to when the patient is in fluid balance. This "euvolemic state" should be determined by the health care professional. Once a patient’s dry weight is identified, a patient can monitor their weight daily in the morning before eating to ensure that it is stable, and their symptoms are controlled.
Sometimes weight will vary by a few pounds during the week even in patients who are compliant with their medications and diet. However larger changes in weight (>5 pounds) can help indicate that a patient is not taking medications as prescribed or following a recommended diet. Large weight changes may also mean that a patient’s disease has progressed and he or she now needs to take higher dosages of a diuretic and reduce fluid intake.
A diuretic, sometimes called a water pill, removes fluid through increased urination with the goal of preventing flare-ups or worsening of symptoms, which can require hospitalization and more aggressive treatment to remove fluid.
On the other end of the spectrum, more severe cases of heart failure are associated with weight loss secondary to "cardiac cachexia," which can indicate progression to more advanced disease.
Physical activity guidelines for adults recommend at least 150 minutes per week (for example 30 minutes, five days/week) of moderate intensity exercise and at least two days of light to moderate resistance exercises.
While chronic conditions like osteoarthritis may impede patients from following these recommendations, it should not discourage efforts at sustained lifestyle improvements. Several large studies have concluded that the least physically active individuals benefit the most by even modest but sustained increases in their physical activity level. Also, if individuals are unable to tolerate higher-impact activity like brisk walking or jogging, moderate amounts of swimming, walking in a pool, elliptical training, and cycling are great low-impact alternatives.
In addition, heart failure guidelines recommend regular physical activity as a safe and effective option to improve functional status in patients with heart failure. In fact, cardiac rehabilitation, which is a controlled environment for heart failure patients to exercise while monitored by health care professionals, provides patients an opportunity to improve functional capacity, exercise duration, and quality of life.
Patients with high blood pressure, diabetes, increased weight, and high cholesterol are at risk for heart failure but may not develop structural or symptomatic disease. In addition, each of these conditions is a well-known risk factor for developing coronary artery disease. Heart attacks are responsible for roughly two-thirds of all heart failure cases. Controlling risk factors like diabetes and high blood pressure to prevent development of obstructive coronary artery disease and signs and symptoms of heart failure is critical.
The first goal of therapy is behavioral and lifestyle changes. These include to stop smoking, increase physical activity levels, and follow a heart-healthy diet. The next step focuses on managing risk factors such as blood pressure, cholesterol, and diabetes control.
Given the significant overlap in the treatments to control risk factors and heart failure, many individuals are already on appropriate treatments when they progress to having signs and symptoms of heart failure. In those individuals, the focus should be on increasing the doses of the heart failure medications to achieve levels that are proven to reduce morbidity and mortality.
In those individuals not on guideline-directed medical therapy, a combination of ACE-I, ARB, or ARNI, beta-blocker, statin, diuretic, and mineralocorticoid receptor antagonist (MRA) will be implemented with the goal of preventing symptoms, changes to the chambers of the heart, hospitalizations, reductions in quality of life, and ultimately mortality.
Recent trials have shown that a particular class of diabetes medication known as an SGLT2 inhibitor can reduce the occurrence of heart failure hospitalizations.
In summary, patients with a history of heart failure should discuss the ABCDEs of comprehensive cardiovascular disease management with their health care provider:
A: Antiplatelet (e.g. aspirin) or Anticoagulant therapy
A: ACE-I, ARB, ARNI, MRA
B: Beta blocker
B: Blood pressure
C: Cigarette Cessation
D: Diet/weight guidance
D: Diabetes prevention/management
David I. Feldman, MD, MPH, is an internal medicine resident at Johns Hopkins. Kim Cuomo, CRNP, is the manager of the hospital's Heart Failure Bridge Clinic. Roger S. Blumenthal, MD, FACC, is the Director of Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Roberta Florido, MD, MHS, is a cardiologist and professor at Johns Hopkins.